Starting the conversation - Integrating mental health into maternal health care in India.

The perinatal period is considered the most vulnerable time in a woman's lifespan for developing mental health problems1. This is also the period most suiTable for intervention as women are likely to be in regular contact with the health system. Low- and middle- income countries (LAMI) have been found to have a higher prevalence of perinatal mental health problems2 and higher rates of maternal suicide often driven by external factors such as marital conflict and interpersonal violence34.

There is sufficient evidence to show that postpartum depression is a strong predictor of parenting stress, negatively impacting mother-infant bonding5 and leading to cognitive, emotional and behavioural problems in children67. However, less well known is the impact of antenatal depression and anxiety, which can lead to adverse obstetric outcomes such as placental insufficiency, preterm labour and low birth weight8. Antenatal mental health problems are also associated with poor nutrition, inadequate weight gain and irregular antenatal appointments910. Children of mothers who have depression or anxiety are more susceptible to attention deficit hyperactivity disorder (ADHD), conduct disorders and emotional problems11. Infants of mothers with depression in LAMI countries have high rates of malnutrition, diarrhoea, infections, hospital admissions, and incomplete immunization schedules312.

With this available evidence, many high- income countries such as the UK, Australia, Norway and the US, have integrated early identification and treatment of perinatal depression into standard healthcare protocols131415. Addressing maternal mental health will be a major step to ensuring healthy babies and decreasing maternal morbidity. However, there are a few challenges to the introduction of routine maternal mental health screening in India. The first will be the lack of awareness of its importance among obstetricians and other healthcare workers involved in antenatal and postnatal care. In the face of more pressing problems such as anaemia and poor access to hospital deliveries, mental health may not get the priority that it warrants. The second challenge is to find a suiTable tool that can work in different settings and with mothers with varying literacy levels.

Translated versions of the Edinburgh Postnatal Depression Scale (EPDS) which is the most widely used scale, have their limitations when used in non-western settings1617 and a simpler tool that can be used by all health workers needs to be considered, which can also help with easy triaging.

The final challenge is to develop access pathways using a stepped-care approach. Different models need to be developed that take into account the pockets of resource intensive sectors amidst vast areas of limited resources. Several solutions are possible to meet these challenges. Upskilling existing community healthcare workers has been tried successfully in South Asian settings181920 which could be a starting point for establishing primary care. Existing counsellors and psychologists could be identified as points of referral for secondary care21. Sensitizing obstetricians and paediatricians will ensure that women do not get missed during the antenatal and postnatal periods while a mental health specialist in a district or general hospital could be identified as a point of referral for women with serious mental illness for intensive care22. With the strengthening of the District Mental Health Programme, such a care pathway is possible. This will also ensure continuity in delivery of services.

In India, the effective use of technology to educate health workers and primary care doctors in mental health has been met with success23. Such a model can be easily implemented to support and guide primary healthcare staff in screening, early interventions and referrals. Such integration will also help in decreasing the stigma related to mental health and viewing it as yet another component of holistic health care.

It is time to start the conversation on maternal mental health and adopt some of the good practices being followed in other countries. Addressing mental health in the perinatal period provides a great opportunity for early intervention not only for the mother and infant, but also for adolescent and adult mental health and behaviour, which eventually affects the entire society.